Incorporating Public Values Through Multiple Accountability: A Case Study on Quality Regulation of Emergency Care in the Netherlands by an Independent Regulatory Agency

• Author: Diana Delnoij,Jolien van de Sande,Antoinette de Bont,Bert de Graaff
• Published date: 01 July 2022
• DOI: 10.1177/00953997211057056
• Date: 01 July 2022
• Subject Matter: Articles

https://doi.org/10.1177/00953997211057056

Administration & Society

2022, Vol. 54(6) 1178 –1206

© The Author(s) 2021

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DOI: 10.1177/00953997211057056

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Article

Incorporating Public

Values Through Multiple

Accountability: A

Case Study on Quality

Regulation of Emergency

Care in the Netherlands

by an Independent

Regulatory Agency

Jolien van de Sande1, Bert de Graaff1,

Diana Delnoij1,2, and Antoinette de Bont1

Abstract

In this paper, we explore how multiple accountability (MA) can enable an

independent regulatory agency to deal with multiple conflicting public values

in a complex and politically salient decision-making process. We examined

the decision-making process of the Dutch National Health Care Institute

on quality regulation of emergency care in the Netherlands. Using insights

derived from ethnography, document analysis, and interviews, we show that

MA resulted from strategic interactions between the Institute’s vertical and

horizontal accountability forums. We argue that MA impeded efficiency but

also enabled the Institute to deal with multiple conflicting public values.

Keywords

public accountability, multiple accountability, public values, conflicting values,

independent regulatory agencies, emergency care

1Erasmus University Rotterdam, The Netherlands

2National Health Care Institute, Diemen, The Netherlands

Corresponding Author:

Jolien van de Sande, Erasmus School of Health Policy and Management, Erasmus University

Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands.

Email: vandesande@eshpm.eur.nl

1057056AAS0010.1177/00953997211057056Administration & Societyvan de Sande et al.

research-article2021

van de Sande et al. 1179

Introduction

Since the 1980s, the privatization and reregulation of public services in the

context of new public management reforms has led to a shift from govern-

ment to systems of dispersed governance in many European countries

(Bovens & Schillemans, 2014; Majone, 1994). These developments have

restricted hierarchical influence and have sparked a tendency to introduce

new accountability practices to overcome accountability deficits in policy-

making (Schillemans, 2011). A large body of accountability research focuses

on the public accountability of independent regulatory agencies (IRAs), to

which governments have increasingly delegated tasks (Helderman et al.,

2012; Majone, 1994). As ministerial control on these agencies is limited, they

are not affected by traditional democratic accountability through elections

(Durose et al., 2015).

This accountability deficit is particularly perceived as pressing since agen-

cies often execute substantive tasks. Therefore, they give a certain meaning

to political values when making decisions and these analyses cannot be laid

down in legal procedures (Bach & Jann, 2010; Eriksen, 2021; Majone, 1996).

Although much research has been done on value conflict, finding better ways

to deal with different values remains a pressing issue for policymakers

(Kernaghan, 2003). Besides coping with different (often conflicting) values,

agencies must deal with numerous accountability practices because of their

accountability deficit. This phenomenon is called multiple accountability

(MA). Scholars have largely focused on the drawbacks of MA, such as high

costs, pressure on public officials, politicization, and confusion (Flinders,

2011; Koppell, 2005; Willems & Van Dooren, 2012).

However, the benefits of MA, such as increased reliability of oversight

and reduction of information asymmetry, have also been investigated

(Schillemans, 2010). In our ethnographic study, we will focus on the benefit

addressed by both Scott (2000) and Schillemans (2010), who state that MA

balances different values because different forums have competing agendas,

concerns, powers, procedures, and capacities. Previous empirical research

that addresses how organizations and individuals deal with competing values

and accountability shows the often complex, messy, and political nature of

these processes. Oldenhof et al. (2014) conducted observations and inter-

views to show how public managers use justifications to deal with value con-

flicts in their daily work. Brunsson (1989, pp. 4–9) finds that, to survive,

organizations strategically try to gain legitimacy through the creation of

structures, processes, and ideologies which reflect the inconsistent norms in

their environment. The well-known garbage can process that Cohen et al.

(1972) describe is more coincidental. It stresses that outcomes are determined